Domestic violence screening

Have I written about this before? It seems like I must have. I certainly have been bombarded with the idea that doctors should screen their patients for relationship/domestic violence during these last several weeks. And the idea continues to appear no less ill-conceived.
As any good epidemiologist knows, if you are going to screen for some condition, that condition should meet two basic criteria:
1. the condition you are screening for should be asymptomatic
2. intervening earlier should have some effect on the disease process in terms decreasing morbidity and mortality.
There is also the issue of cost-effectiveness which it only makes sense to talk about once criteria 1 and 2 are met. Domestic violence fails to meet the first criteria – it is not asymptomatic. Getting hit, kicked or raped by your partner are all symptoms of domestic violence. By screening for it, we are not using our medical expertise to identify a condition for which we can intervene, thereby helping our patients live longer and healthier. What we are doing is identifying a condition that our patients already know that they have (because the only way we know they have it is by asking them) and then telling them that it’s a problem. Telling patients what is or is not a problem rather than letting them decide for themselves is pretty much the definition of paternalism.
I don’t deny that the prevalence of domestic and relationship violence is huge. Nor that there are thousands of women out there in very bad situations. And I’m glad that there are some resources that these women have available to tap into. But, I don’t believe that there is anything about medical school or residency training that confers the expectation upon doctors that they identify ALL of their patient’s problems and try to solve them. Patient’s may have a whole host of problems which doctors are equally unqualified to deal with. Should we screen our patients for excessive credit card debt? Excessive debt can cause huge emotional distress, bankrupcy and can ruin lives. But, I’ve never heard of any doctors advocating that we should screen for excessive credit card debt. Why is domestic violence different?
Now, if a person comes in complaining that they’re being abused by their domestic partner, I’m more than happy to put her in touch with appropriate resources. But this is not the same as screening. This is a case of the patient having identified a problem and asking for help. And, as a doctor, I will provide whatever help I can. But seeking out patients via screening in whom you try to identify an additional problem? This is fine for conditions like diabetes, hypertension and cervical cancer – conditions for which our medical training has supplied us with privileged information about how much of a problem the condition may or may not be for the patient. But we have no privileged information about how much of a problem the behavior of our patient’s boyfriend is for her. She is much more qualified to make that determination than we are. Therefore, in the final analysis, it simply is not a doctor’s place to screen for domestic violence.

3 responses to “Domestic violence screening”

I think dealing with DV is a tough situation for docs because of time constraints (docs don’t get to bill more for a DV screening) and especially because the health care system is not well equipped to deal with DV (other than to patch people up after physical abuse). But to think that docs have no role in identifying DV when DV clearly is something associated with adverse physical and psychological outcomes is mistaken. What’s more, your arguments against routine DV screening kind of fall flat.
DV can, in fact, be ‘asymptomatic.’ Sure, a person knows when she (or he) is being hit, but that may or may not be perceived by the patient as abuse. (There’s increasing awareness of DV but, still, a surprising number of victims believe, on some level, that they deserved the abuse, or even that abuse is a normal part of an intimate relationship.) And, interestingly, you don’t mention emotional abuse at all although emotional abuse is more likely that physical abuse to go unrecognized as DV by victims.
You also say telling patients what is and is not a problem is paternalism. However, there is a difference between saying, “Your boyfriend hits you, therefore, you have a problem with DV and you must leave him,” and giving a patient info about DV. It’s inappropriate for a doc to tell a patient how to live his/her life, but well within the realm of doctorly duties to advise and inform patients about behaviors that can improve health and quality of life.
Finally, you say that docs have no privileged information about the impact of DV on patients. Info could be obtained, though, by querying patients and/or relying on research data, similar to what is done for other issues. For example, think how docs determine the impact of not wearing a seatbelt or problem drinking, two things commonly screened for.
Better arguments against routine screening might be the lack of a validated screening instrument for DV and minimal existing research showing that screening improves outcomes. However, these are not so much arguments against screening as they are indications that more work/research should be done in this area, so as to better equip docs to deal with DV. Until such time that better data exists, considering the cost of screening (in terms of a doc’s time) is minimal and intuitively there is potential benefit (and probably no harm), it seems docs should err on the side of screening rather than not screening.

Thanks for the thoughtful response to my post, Parlancheq. You wrote it almost a year ago and I just happened to read it today :) Although I respectfully disagree with what you have to say, the one thing I will respond to is what you say at the end, “It seems docs should err on the side of screening rather than not screening.” If this blog has any mission at all in life, it’s to convince people that this is absolutely incorrect thinking. When there is no evidence to direct us one way or the other, doctors should err on the side of NOT screening. First do no harm, right? Do we believe this anymore? Every time we screen for something, we are giving ourselves an opportunity to intervene. And every time we intervene, we are giving ourselves an opportunity to harm our patients. First do no harm.

I was looking back at an old postand happened to read this comment. In response, I wrote the following: Thanks for the thoughtful response to my post, Parlancheq. You wrote it almost a year ago and I just happened to…